Although pay-for-performance (P4P) is an intimidating concept for many clinicians, it is rapidly working its way into healthcare delivery, according to speakers at a panel discussion at Chest 2010. P4P relies on the use of evidence-based medicine, which can be defined as “the integration of the best research evidence with clinical expertise and patient values,” said Michael H. Baumann, MD, MS, Chief Quality Officer and Professor of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Mississippi, Jackson.
Performance measures are a hot topic as a result of the projected increase in health expenditures in the United States. Health spending was 16.6% of the gross domestic product (GDP) in 2008, up from 15.3% in 2002, and is projected to be 19.6% of the GDP in 2019. The wide variation between health costs and outcomes has fueled government scrutiny and the adoption of performance measures as a way to improve patient outcomes and quality of care.
The recommendations generated from evidence-based medicine are often turned into performance measures, Dr Baumann said. Performance measures are a tool to evaluate the extent to which the actions of a healthcare provider conform to practice guidelines or standards of quality. It can also be considered a value against which the performance of an individual, group, or hospital can be compared, or benchmarked.
The components of a “good” performance measure, as defined by the National Quality Forum, include scientific acceptability (it produces consistent or credible results when implemented), usability (the intended audience understands the results and can use them for decisions), and feasibility (the data are obtained in normal workflow).
P4P, also known as value-based performance, is based on critical measures by which a physician’s performance is compared with clinical benchmarks. The individual’s performance level then determines his or her reimbursement.
“Pay-for-performance is already out there,” Dr Baumann said. For example, the Centers for Medicare & Medicaid Services (CMS) is running a Premier Hospital Quality Incentive Demonstration (HQID), in which hospitals receive incentive payments based on performance, improvement in performance, and attaining medianlevel composite quality scores.
Hospitals participating in HQID raised their overall quality by an average of 18.3% over 5 years, based on delivery of standardized care measures in 6 clinical areas.
CMS also produces a “Hospital Compare” website—a consumer-oriented website that provides information on how well hospitals provided recommended care to patients, Dr Baumann noted.
The challenges for performance measurement include the time lag in adopting data to keep up with new therapies, said Jun Chiong, MD, Director of the Advanced Heart Failure Program and Associate Professor of Medicine, Pharmacology and Outcomes Science, Loma Linda University, CA.
In the case of heart failure and other diseases, correct dosing of an indicated medication is crucial to optimal outcomes, so performance measures should go beyond “just the percentage of patients on a given drug,” Dr Chiong said. He also asked whether hospital stay is a valid performance measure, or if outcomes downstream should be included in a measure.
In ranking hospitals’ performance, being small has an advantage, Dr Chiong said. In a study of performance measures for acute heart attack from more than 3700 US hospitals, large-volume hospitals were found to have better aggregate performance measures (ie, use of beta-blocker treatment) but were less likely to be identified as a top hospital because of the unequal denominators (number of cases).